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Thursday, November 14

Gender Dysphoria
DSM-V
and Gender Identity Disorder (DSM-IV)

Outline for today

What is Gender Dysphoria?

Review: DSM as socially constructed

Gender Identity Disorder (DSM-IV)

Film: No Dumb Questions
Gender Dysphoria (DSM-V)

Example: Homosexuality

Summary of changes from DSM-IV to DSM-V

and discussion throughout!

What is Gender Dysphoria?

People whose gender at birth is contrary to the one

they identify with

Children, adolescents, adults

Gender incongruence distress Gender

Dysphoria

Gender noncomformity itself not a mental disorder

so why is it in the DSM?

Review:
The

DSM is a politically and

economically charged document
that is largely socially
constructed.
1.

Political, e.g., homosexuality

2.

Economic, e.g., billing

Social, e.g., dependent on social

norms

3.

History of Homosexuality in the DSM

12th century: hostility toward homosexuality (sinful)

Late 19th century: viewed as pathology (illness less
blameful)
1950s onward: scientific evidence suggests
homosexuality not a psychological disturbance
1973: homosexuality removed from DSM, but
replaced with ego-dystonic
homosexuality (incorporates distress into diagnosis)
1986: DSM sexual disorders not otherwise
specified persistent and marked distress about
ones sexual orientation

DSM-IV Gender Identity Disorder

Section: Sexual and Gender Identity Disorders

Sexual dysfunctions

Paraphilias

i.e., female/male hypoactive sexual desire disorder, sexual aversion

disorder, male erectile disorder, female sexual arousal disorder, etc.
i.e., exhibitionism, fetishism, pedophilia, sexual sadism/masochism,
etc.

Gender identity disorders

Gender identity disorder

302.85 In adolescents or adults

302.6 In children
302.6 Gender identity disorder not otherwise specified

302.9 Sexual disorder not otherwise specified

Gender Identity Disorder: 4 diagnostic criteria

DSM-IV Gender Identity Disorder

Criterion A: strong and persistent cross-gender

identification

Children: 4 or more of the following:

Repeatedly stated desire to be (or insistence that he/she is) the

other sex
Boys: preference for cross-dressing / female attire; Girls: insistence
on wearing only stereotypical masculine clothing
Strong and persistent preferences for cross-sex roles in makebelieve play, persistent fantasies of being the other sex
Intense desire to participate in stereotypical games/pastimes of the
other sex
Strong preference for playmates of the other sex

Adolescents/Adults

Stated desire to be the other sex, frequent passing as the other

sex, desire to live or be treated as the other sex, conviction that he/
she has the typical feelings/reactions of the other sex

DSM-IV Gender Identity Disorder

Criterion B: persistent discomfort with ones sex

Children

Boys: assertion that penis/testes are disgusting; aversion to roughand-tumble play, rejection of male stereotypical toys, games,
activities
Girls: assertion that she will grow a penis, or that she doesnt not
want to grow breasts or menstruate; marked aversion toward
normative feminine clothing

Adults: preoccupation with getting rid of sex characteristics

(hormones, surgery, etc.) or belief that he/she was born the
wrong sex

Criterion C: not concurrent with physical intersex

condition
Criterion D: causes clinically significant distress or
impairment

DSM-IV Gender Identity Disorder

Summary

Strong and persistent cross-gender identification

Persistent discomfort about ones assigned sex
Clinically significant distress

Specifiers

Sexual orientation (sexually attracted to males, females,

both, or neither)

Film: No Dumb Questions

Uncle Bill is becoming a woman!

This lighthearted and poignant documentary profiles
three sisters, ages 6, 9 and 11, struggling to understand
why and how their Uncle Bill is becoming a woman.
These girls love their Uncle Bill, but will they feel the
same way when he becomes their new Aunt Barbara?
With just weeks until Bill's first visit as Barbara, the
sisters navigate the complex territories of anatomy,
sexuality, personality, gender and fashion. Their reactions
are funny, touching, and distinctly different.
This film offers a fresh perspective on a complex situation
from a family that insists there are no dumb questions.

Review: Stigma

Replacing Gender Identity Disorder with Gender

Dysphoria

More accurate label

Removes connotation that patient is disordered

Begins to remove stigma

DSM-V: Gender Dysphoria 

Terminology

In English, sex connotes male/female AND sexuality

In DSM-V

Sex/sexual: biological indicators of male/female

Gender: the public lived role as boy/girl, man/woman

Disorders of sex development

Cross-sex hormone treatment
Biological X social/psychological factors contribute to gender development
Gender assignment: initial assignment at birth as male or female
Gender atypical (or gender nonconforming): somatic features or behaviors
not typical of individuals with the same assigned gender
Gender identity: social identity as male, female, or another category
Gender dysphoria: affective/cognitive discontent with assigned gender

Transgender: individuals who identify with gender different than

their assigned gender
Transsexual: individuals who seek or have undergone a social
transition from malefemale or female male

DSM-V: Gender Dysphoria

Diagnostic Criteria for Children

Criterion A: a marked incongruence between ones

experienced/expressed gender and assigned gender, of at
least 6 months duration, manifested by at least 6 of the
following:

Strong desire to be of (or insistence that he/she is) the other

gender (or some alternative gender)
Strong preference for cross-gender dressing
Strong preference for cross-gender roles in play
Strong preference for stereotypically cross-gender toys
Strong preference for playmates of the other gender
Strong rejection of typical toys/games of assigned gender
Strong dislike of ones sexual anatomy
Strong desire for sex characteristics that match experienced
gender

Criterion B: associated clinically significant distress or

impairment
Specify if with a disorder of sex development

DSM-V: Gender Dysphoria

Diagnostic Criteria for Adolescents & Adults

Criterion A: a marked incongruence between ones

experienced/expressed gender and assigned gender, of
at least 6 months duration, manifested by at least 2 of the
following:

Marked incongruence between ones experienced/expressed

gender and ones sex characteristics
Strong desire to be rid of ones sex characteristics
Strong desire for sex characteristics of other gender
Strong desire to be of the other gender
Strong desire to be treated as the other gender
Strong conviction that one has typical feelings/reactions of
other gender

Criterion B: associated clinically significant distress or

impairment
Specify if with a disorder of sex development
Specify if posttransition (full-time living in desired gender)

DSM-V: Gender Dysphoria

Prognosis

Early-onset gender dysphoria

Onset between 2-4 years (developmental stage

gendered behavior)
Anatomic dysphoria heightens in anticipation of puberty
Persistence (2-30% in natal males; 12-50% in natal
females) modestly correlated with severity

Therapeutic approaches? Supportive family/social environment?

Sexual attraction to own natal sex

For those whose gender dysphoria does not persist

63-100% of natal males identify as gay
32-50% of natal females identify as lesbian

Video: http://www.youtube.com/watch?v=QxhyFA8iV9o

DSM-V: Gender Dysphoria

Prognosis

Late-onset gender dysphoria

Dysphoria begins at puberty or much later

Much more common in natal males
May have more fluctuations in degree of gender
dysphoria and less likely satisfied after gender
reassignment surgery

Gender dysphoria in association with disorder of sex

development

Uncertainty experienced, rather than firm conviction about

gender

DSM-V: Gender Dysphoria

Epidemiology

These may be modest estimates

Prevalence:

Gender (referral rates):

Approximately 1 in 7,000-20,000 natal males

Approximately 1 in 30,000-50,000 natal females
In children, 2-4.5x more natal boys than girls
In adolescents, equal number of natal boys and girls
In adults, 1-6x more natal males than females

Cross-cultural:

In Japan and Poland, more common in natal females

DSM-V: Gender Dysphoria

Etiology

Largely unknown!

Environmental factors:

Genetic factors:

Natal males with gender dysphoria more commonly have an

older brother than males without gender dysphoria
General social, psychological, or developmental problems may
predispose natal males for late-onset gender dysphoria
Some weak evidence for genetic contribution

Biological factors:

No hormonal abnormalities in natal males; but increased

androgen in natal females
Atypical prenatal androgen production and utilization (more
related to gendered behavior than gender identity)

DSM-V: Gender Dysphoria

Treatment

Also controversial!

Video: http://www.youtube.com/watch?v=z8Iq3E85-VY

Psychological therapy/counseling
For early-onset gender dysphoria

2 choices at early puberty

Puberty blocking medications pause puberty 3-4 years

Cross-sex hormone treatments (less common)
Progress through puberty in chosen gender
Long-term implications: sterility

Balance: costs of treating vs. not treating

Video: http://www.youtube.com/watch?v=vsVV_CEd7_Y

Gender reassignment surgery (not legal for children)

From Gender Identity Disorder to Gender Dysphoria

Focus on cross-gender
identification
Included in section with
sexual dysfunctions and
paraphilias
Dichotomized diagnosis

Criteria A (cross-gender
identification) & B (aversion
towards ones gender)
sex
Sexual orientation specifier

No posttransition specifier

Focus on gender
incongruence
Gender Dysphoria its own
section
Type and severity can be
inferred
Merged into Criterion A
gender
No sexual orientation
specifier
Posttransition specifier